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Failure to Thrive

11/13/2012

A three-week-old boy born full-term, normal spontaneous vaginal delivery without complication is brought in by his father because he received a letter in the mail that he did not understand about some laboratory tests for his son. The father is not sure about the baby’s eating habits, but states that “he’s a crier”, and sometimes vomits before feedings. He is afebrile and his vital signs are normal. The physical exam is significant for a sleepy newborn with a hyperpigmented scrotum. His weight is 3.7 kg, the same as his birth weight. What is the most appropriate management?

A.   Do a head-to-toe exam looking for causes of “increased crying”, and, if negative and tolerates fluids by mouth, refer to his pediatrician.
B.   Check the baby’s blood glucose, and if normal and eating in the ED, refer to his pediatrician.
C.   After a thorough history and physical, if negative, refer to Failure to Thrive clinic
D.   Draw blood for serum chemistry

In the meantime, a quote -- "In the presence of the patient, Latin is the language." -Medieval medical saying

Answer

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Unresponsive

11/5/2012

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A 52-year-old woman with diabetes mellitus type II, hypertension, and obesity arrives to the ED complaining of total body pain, palpitations, and fatigue over the past few weeks.

While waiting for evaluation she becomes anxious, diaphoretic, and slumps down into the gurney. She appears to be unresponsive.

Regarding her immediate management, which of the following is the BEST answer:

    A.     Initiate BLS maneuvers with “look, listen, and feel”
    B.     Take her pulse for up to 30 seconds and extrapolate beats per minute – this may be extreme bradycardia
    C.     Call for help and start compressions now
    D.     When another provider arrives, initiate ratio of 15 compressions to two breaths

In the meantime, a quote -- "All diagnoses are provisional formulae for action." Henry Cohen, MD Lancet 1:23-25, 1943

Answer

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Abdominal Mass

10/29/2012

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A four-year-old boy is brought in by his mother for 3 weeks of abdominal pain, having been to two other EDs this week, diagnosed with constipation. She brings him in today because now he has two days of “red urine”. No fever, nausea, vomiting, or diarrhea. He is eating well. T 37.9 HR 100 100/60 RR 22 100% RA. He has no tenderness to palpation on abdominal exam, but has what appears to be a left flank-abdominal mass. While he is waiting to be registered, his mother notes that he is “acting funny – why is he so tired?”. You re-examine him to find an altered young boy, diaphoretic, HR 120. Which of the following is the best choice for immediate intervention?

    A.   Initiate fluid resuscitation with 20 mL/kg IV bolus over five minutes
    B.   Give 3 mL/kg of 10% dextrose and monitor
    C.   Give Tylenol 15 mg/kg PR and re-assess
    D.   Give 2 mL/kg 25% dextrose and monitor

In the meantime, a quote -- "Medicine is not a field in which sheep may safely graze."

Answer

1 Comment

My Heart is Pounding!

10/22/2012

1 Comment

A 55-year-old woman with a history of anxiety and hypertension complains of palpitations increasing in frequency over the past week. She is under considerably more stress at work, with job cuts looming for several employees. Her last episode was typical of her previous – it lasted two to three minutes while she was at her desk: “my heart was pounding so badly it went up my neck and into my head!” She has no complaints of chest pain, shortness of breath, nausea, or diaphoresis with these episodes. The remainder of her history is unrevealing and her vital signs and physical examination are normal. Her electrocardiogram (ECG) in the ED is normal.

Regarding this patient’s risk for an arrhythmia, which of the following is the BEST answer:

    A.     Her history puts her at high risk for a significant arrhythmia
    B.     A normal examination and a normal ECG in this patient make a clinically  significant arrhythmia much less likely
    C.    Her lack of high risk symptoms places her at low to moderate risk for an arrhythmia
    D.    Her history of anxiety should be pursued further .

In the meantime, a quote -- "Your prayer must be for a sound mind in a sound body (mens sana in corpore sano)." -- Juvenal, Roman satirist, c. AD 60-130

Answer

1 Comment

Agitation

10/15/2012

3 Comments

A 13-year-old girl is brought in by ambulance after her friends called because she was “acting stupid”. The paramedics report that the other girls mentioned her snorting some “Vanilla Sky”.

On arrival, you see an agitated, hallucinating young girl without evidence of trauma; her glucose in the field is 122. T 37.9 HR 118 BP 142/68 RR 22 98% RA. Her general exam is significant for diaphoresis, slight tremulousness, reactive 5 mm pupils bilaterally, and a tachycardic exam.   Her friends arrive soon after frantically roaming the department, offering no useful information, and quickly leaving after seeing her lying in the gurney.

Regarding her presentation, which of the following is the BEST answer:

    A.    Her large pupils are pathognomonic for anticholinergic toxicity
    B.    Her elevated heart rate indicates that she must have taken a hallucinogenic agent
    C.    Her diaphoresis helps to distinguish the toxidrome
    D.    This particular drug causes mydriasis, profound obtundation or coma, and rapid resolution

In the meantime, a quote -- "When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it." --Louis Pasteur (1822-1885) Address to École Centrale des Arts et Manufactures, Paris, 1884

Answer

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Wheezing after IV Contrast

10/9/2012

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A 66-year-old man with a history of hypertension and smoking complains of acute-on-chronic dull, unrelenting abdominal and back pain over the past several hours. He has been “under a lot of stress lately” and occasionally suffers from anxiety. He has no fever, nausea, vomiting, or diarrhea. His vital signs show T 37.8 HR 92 BP 166/80 RR 12 98% RA. His exam shows diffuse mild abdominal tenderness to deep palpation; he has normal pulses. A bedside ultrasound of his abdomen is very limited by habitus and bowel gas.

A CT abdomen/pelvis is ordered with IV contrast. During the scan, your patient has difficulty breathing and becomes diaphoretic. You respond to the radiology suite to find a flushed man in moderate distress with wheezing. Regarding his management, which of the following is the single BEST answer:

    A)     He should never be given IV contrast again
    B)     Give steroids and diphenhydramine and watch for improvement; hold the epinephrine for now due to his age     and risk factor.
    C)     Give 0.5 mg of 1:1,000 epinephrine IM now.
    D)     Give 0.3 mg of 1:10,000 epinephrine IM now

In the meantime, a quote -- "For want of timely care, Millions have died of medicable wounds." - John Armstrong, physician and poet (1710-79) Act of Preserving Health

Answer

3 Comments

Knee Pain

10/1/2012

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An 11-year-old boy presents with acute onset left knee pain. The boy states that he was running the bases during a baseball game, when he felt a “pop”, and fell on his left knee. He has no past medical history. On exam, he has normal vital signs. His head-to-toe exam is normal, except for a swollen and painful left knee; he is neurovascularly intact distally.

His left knee plain radiographs are below:

Regarding his presentation and management, which of the following is the BEST answer:

    A.    This is a common presentation in his age range; once reduced, his fracture will heal readily
    B.    This is a significant comminuted fracture as demonstrated by the lateral film; he will require an intramedullary rod
    C.    He will require both medical and surgical intensive treatment
    D.    He should be evaluated for a deep bone infection

Answer

3 Comments

Red Toe

9/24/2012

1 Comment

A 67-year-old man with diabetes mellitus, hypertension, and renal insufficiency arrives to the emergency department with three hours of right great toe pain and swelling. When pressed, he reluctantly confirms a past diagnosis of gout, and his not taking his urate-lowering agent. On exam, you see a man in moderate distress due to pain; he is mildy volume depleted. T 38.3 HR 96 BP 170/90 RR 20 98% RA. His right first metatarsal joint is red, warm, and swollen. On further exam, his left knee, right elbow, and right second metacarpophalangeal joint are mildly swollen and painful.   The rest of his history and physical examination are unremarkable.

Regarding the management of this patient, which of the following is TRUE:

    A. Allopurinol, a xanthine oxidase inhibitor, is indicated to abort this gouty flare
    B. High-dose colchicine is a safe, effective, and first-line treatment
    C. The presence of podagra is a reliable indicator of a gouty flare
    D. NSAIDs such as aspirin are effective in treating gouty flares

In the meantime, a quote -- "The gout is so common a disease, that there is scarcely a man in the world, whether he has had it or not, but thinks he knows perfectly what it is." William Cadogan (1711-97), A Dissertation on the Gout, and All Chronic Diseases, Jointly Considered

Answer

1 Comment

Groin Swelling

9/16/2012

3 Comments

A two-month-old boy born at 34 weeks gestation is sent from his pediatrician’s office for a mass in his groin. His mother did not notice it herself; the child has been eating, sleeping, and eliminating well. There has been no fever, vomiting, or change in behavior. On exam, you see a well appearing infant with a trace non-tender right inguinal mass that readily disappears with mild pressure.

Regarding this child’s presentation and management, which of the following is TRUE:

A. This child is at high risk for incarceration; he should be admitted with plans for
surgery in the next 24 hours
B. Given his physical exam, this child likely has a hydrocoele
C. This child needs an ultrasound to rule out testicular torsion
D. This child is at low risk and can be discharged with outpatient follow-up

Answer

3 Comments

Femur Fracture

9/10/2012

4 Comments

A 40-year-old man with no past medical history was riding his bicycle when he rode over a large pothole in the road, fell to the curb, and sustained a closed mid-shaft right femur fracture. He has no other trauma, is neurologically intact with normal distal perfusion. He will need a Steinmann traction pin placed in the ED and will be on call to the OR tomorrow. Your colleague suggests ketofol for sedation for the ED procedure. Which of the following is BEST supported by the current evidence?

Ketofol has been shown to allow for faster recovery and faster disposition
Ketofol has a lower incidence of adverse airway events
Ketofol has the same efficiency profile as propofol
Ketofol is associated with higher patient satisfaction scores

Answer

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Failure to Thrive

Unresponsive

Abdominal Mass

My Heart is Pounding!

Agitation

Wheezing after IV Contrast

Knee Pain

Red Toe

Groin Swelling

Femur Fracture

Timothy Horeczko, MD, MSCR, FACEP, FAAP

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